Lessons from the COVID-19 Response

Lessons from the COVID-19 Response

When COVID-19 emerged in late 2019, Breakthrough ACTION was working on social and behavior change for family planning/reproductive health, malaria, HIV, and other health issues across the globe, including under the Global Health Security Agenda. Over the coming months, as it became clear that COVID-19 would touch every community in time, Breakthrough ACTION pivoted. While continuing our work addressing these health areas, Breakthrough ACTION responded to COVID-19 as the crisis it is, implementing activities in 22 countries by June 2020.

We learned a lot. We’d like to share those lessons with you.

Overview of Lessons Learned

We organized our lessons into seven sections, which were inspired by the seven key components of risk communication listed in the World Health Organization’s Joint External Evaluation Tool:[1]

Risk communication systems
Partner coordination
Public communication
Community engagement
Uncertainty and misinformation
Capacity and skills
Data and monitoring

Each section includes an overview of what we learned, a case study, and tools and resources. We also included a “Get Ready” section, which is simply a list of specific steps you can take now to help you be ready for the next crisis.

Risk Communication Partner Coordination Public Communication Community Engagement Uncertainty/ Misinformation Capacity & Skills Data & Monitoring

Lessons Learned

Risk Communication Systems: Lessons Learned

A fast and effective start-up is critical in a crisis. The response can’t wait. Projects and organizations that have capable staff and functioning systems already in place before the crisis arrives will be able to start up faster and more effectively. Recruiting, hiring, on-boarding, and training good staff takes time, so they need to be in place before the crisis hits.
Existing systems can pivot to respond to a crisis. Existing projects are an effective platform for the response, even when the original topic is not related to the crisis. A thriving, fully staffed project able to pivot is better placed to respond fast than a disease or crisis-specific project that needs to go through start-up.
Risk communication and community engagement committees are a key part of risk communication systems, and they can be created or reactivated quickly. They work best when the people that make them up have positive existing relationships, when they have worked together or collaborated together in the past, and when they have a baseline of trust. The Global Health Security Agency structure is one way to build or maintain collaboration. Working well together on other health topics also helps.

Case Study

Risk Communication Systems: Case Study

When USAID connected project staff to the Nigeria Centre for Disease Control (NCDC) in March 2020, Breakthrough ACTION’s COVID-19 response in Nigeria began. The NCDC and Federal Ministry of Health recognized Breakthrough ACTION as a lead partner to support risk communication and community engagement (RCCE) activities.

Breakthrough ACTION coordinated messaging efforts at the national level among public sector actors by conducting a situational analysis. Project staff identified what was already being done and where implementation gaps needed to be filled. Airports with international service needed immediate attention and were quickly blanketed with prevention messages even though these locations were not prior implementation states. The analysis was also turned into a work plan that included training of trainers on RCCE for governments across all 36 states and the Federal Capital Territory.

The national government also asked Breakthrough ACTION to help build trust among private stakeholders supporting the response. This led to the development of partner mapping, a community engagement coverage map, and a partner media plan. These mapping initiatives helped stakeholders to understand where support was needed to ensure reliable COVID-19 prevention messages reached all corners of the population.

Once NCDC’s public and private stakeholders achieved a standard competency in the development of risk communication and community engagement messaging, project staff worked closely with them to develop customized work plans. After these plans were activated and messages were developed, Breakthrough ACTION joined a small expert panel to review all advisories, posters, and other materials. NCDC secured exemptions to USAID’s branding and marking requirements, paving the way for Breakthrough ACTION-authored material to easily be reused across the country.

With NCDC leading the panel, project staff shared their expertise in social and behavior change communication and suggest areas for improvement. Space given to partners, including Breakthrough ACTION, to contribute to the COVID-19 response showed NCDC’s leadership and modeled a coordinated and collaborative response to the public health emergency response.

Read more about experiences in Guatemala.

Tools & Resources

Risk Communication Systems: Tools and Resources

COVID-19 Communication Network

Get Ready

Risk Communication Systems: Get Ready

Steps you can take before the next crisis:

Include relationship-building skills in hiring and professional development. Aim for leaders who have good relationships with other partners and counterparts and who invest time in maintaining them.
Join the local Risk Communication and Community Engagement Committee and participate actively. If there isn’t one, start one.

Lessons Learned

Partner Coordination: Lessons Learned

Collaboration relies on communication and trust between people. If partners (the people, not the organizations) have a successful history working together collaboration is likely to work well. Where those relationships don’t yet exist, projects need to invest in them, prioritize them, and build them fast. Mechanisms like GHSA build relationships during regular times that become critical when the crisis hits.
Projects should contribute where they can and let others do the same. Set aside concerns about who gets credit, who covers a certain territory, or who has the specific expertise. Being poised on the ground when the crisis hits is very important to getting work done swiftly.
Government leadership is everything. Clear communication, modeling, and messaging from the government, with a clear lead agency, are essential. Countries without this experience more chaos.

Case Study

Partner Coordination: Case Study

To mobilize quickly, Breakthrough ACTION Sierra Leone built on relationships formed during previous years’ work on priority zoonotic diseases. Project staff were able to quickly take what was learned in creating risk communication, at the national and district levels, and pivot to addressing COVID-19. This was possible through trust and rapport that the project had developed with the manager of the government’s Health Education Division, part of the Ministry of Health and Sanitation, and the One Health Risk Communication Technical Work Group.

With the ministry leading the way, Breakthrough ACTION helped develop a joint COVID-19 response plan that included other partners working in health and development. The plan clarified roles and responsibilities and identified a dedicated group to review messages and materials and provide dissemination recommendations. This process of jointly developing messages and materials systematically borrowed from experiences garnered through addressing rabies, Lassa fever, and swine flu.

Risk communication responses to COVID-19 included support to senior ministry staff to conduct supervision visits with district focal points in order to cascade down COVID-19 prevention information, as well as co-develop custom communication response plans to be implemented within the district. This allowed the ministry and their communication colleagues to put into practice their recently bolstered proficiency in risk communication, including simplifying words related to COVID-19 infection and transmission. As the outbreak progressed, the project created a WhatsApp group to continue to share information between the national and district levels and ensure that new guidance was quickly turned into messages and materials.

The strong foundation developed between Breakthrough ACTION and government partners before COVID-19 hit softened the pandemic’s blow when it arrived in West Africa.

Read more about experiences in Myanmar, Indonesia, Philippines, and South Africa.

Tools & Resources

Partner Coordination: Tools and Resources

Get Ready

Partner Coordination: Get Ready

Steps you can take before the next crisis:

Expand your partnership network. If you always work with the same small set of organizations and people, try to broaden your network of connections, colleagues, and collaborators. This includes relationships with people across government.
Practice collaboration rather than competition. Organizations must compete for funding, so this is a hard balance. When making daily decisions about matters like branding and message harmonization, actively ask yourself whether there is an acceptable option that is more collaborative. You can’t expect to change your project or office culture during a crisis; you have to practice ahead of time.
Plan opportunities to build leadership and coordination skills in government counterparts. Invite them to leadership trainings and other opportunities to develop and practice coordination skills. You never know who will end up in the hot seat when a crisis hits, so don’t worry about inviting only the “right” counterparts.

Lessons Learned

Public Communication: Lessons Learned

Messaging needs to be responsive, adaptive, and flexible. Messaging must respond swiftly to the public’s needs as those needs change. This means projects need two-way communication systems so they know what people are hearing, feeling, doing, and understanding. As messages go out, and information about public needs comes in, projects need to have in place a way to practice adaptive management, i.e., a structured way to constantly learn and change as the environment changes.
Advertising agencies and other creatives are essential partners. Agencies need to be quick and agile as well as effective. Even in crisis and under pressure, a creative agency needs to find ways to gather and use formative research and pre-test products.
Message guides are extraordinarily helpful if they are available at the right time, in the right language(s). Message guides facilitate message harmonization, the practice of ensuring that public communication from different sources says the same basic thing, even if they use different words for different audiences. Having harmonized messages come from credible sources is key; hearing the same message from different trusted sources reinforces its reliability.

Case Study

Public Communication: Case Study

The Breakthrough ACTION COVID-19 response in Guyana included close collaboration with an advertising agency. Staff leveraged their experience with Tagman Media, which was helping develop a multi-channeled SBC campaign to reduce the spread of malaria. When COVID-19 forced project staff to shift priorities, the agency was well-positioned to work hand-in-hand with Breakthrough ACTION. Though under pressure, the partnership easily set up regular meetings and established open lines of communication.

The partnership put together a scope of work to pave the way for the development of a creative brief. This brief laid out the parameters of the COVID-19 campaign, including posters, TV and radio spots, and social media posts. The agency’s creative personnel then produced an overarching creative concept and logo. Project and Ministry of Health staff shared feedback, noting aspects the intended audience might misinterpret. Nine logos were subsequently developed and then narrowed down to a version showing three key prevention behaviors: hand-washing, face coverings, and physical distancing.

The final iteration and accompanying messages were tested via WhatsApp with groups of community members. After a successful pre-test, the agency ensured a unified look for all campaign materials with the theme, “Protecting you, protecting us.”

Without a creative partner, Breakthrough ACTION would have been unable to address the COVID-19 crisis at speed and ensure key messages reached the mining, indigenous, and border communities in Guyana. As new information became available, the agency continued to work alongside the national Health Emergency Operational Center and the Public Relations/Health Promotion Unit to modify the campaign. Editable files were given to these government partners to accommodate further changes in the COVID-19 response, such as the rollout of vaccines.

Read more about experiences in Cambodia, Philippines, and Mozambique.

Tools & Resources

Public Communication: Tools and Resources

Get Ready

Public Communication: Get Ready

Steps you can take before the next crisis:

Build your two-way communication system now. Don’t simply make a plan for one when the next crisis hits; do it now. It can be simple. Use it frequently enough to keep it operational, and experiment with how you can use it to improve programming.
Advocate for message harmonization in your current program area. Whether it is family planning, malaria, or Ebola, message harmonization across programs, projects, partners, and the government is critical. If a harmonization process exists, join it. If one doesn’t exist, try to get it started. At the very least, harmonize messages across parts of large projects: the skill of harmonizing messaging will be useful in a crisis.

Lessons Learned

Community Engagement: Lessons Learned

Community assets are powerful. Use a strengths-based approach to understand what communities already have and use, and build on those assets. Amplifying what communities have (rather than focusing on what they don’t) helps in the short term, because you have a platform for action. But a strengths-based approach can also highlight the community cohesion and skills built during a crisis response that can be used to address other health issues and concerns after the crisis is over.
A system to understand the changing opinions, information, and concerns of the public is important. This could include formal and informal social listening, or the monitoring of social media to track trends in how people are talking about an issue, message, or product.
“Community mobilization” can happen over mobile phones and megaphones; it doesn’t require groups of people in close quarters. However, physically distanced social mobilization should retain as many elements of good community mobilization as possible. Community mobilization should still include human interaction and trusted sources of information, even if it is conducted differently than usual.

Case Study

Community Engagement: Case Study

Risk communication and community engagement go hand in hand. Project staff in Vietnam knew that a successful COVID-19 response depended on genuine community involvement with, and endorsement of, communication campaigns.

They also knew that by using technology familiar to communities, such as loudspeakers and megaphones, Breakthrough ACTION could quickly spread ten key messages on COVID-19 prevention.

Local health workers and community leaders advised staff where to place large amplifiers in ethnic minority communities. These areas included rural hamlets where people tend to congregate, but where other media does not easily reach. Criers drove motorbikes with megaphones mounted on them through sparsely populated areas far from town to complement the loudspeakers.

The messages, based on guidance from the Ministry of Health, focused on wearing masks, hand-washing, social distancing, and identification of suspected cases. To make the call to action more accessible, staff worked with government-designated liaisons to translate and broadcast messages in five ethnic minority languages.

As a vital part of a communication plan that included physically distanced face-to-face conversations, household visits, posters, TV, and radio, the loudspeakers helped reach those without smartphones or access to the internet. Reaching people through lower-tech channels endorsed by authoritative and trusted neighborhood groups and community members drove the adoption of key COVID-19 prevention behaviors.

Read about experiences in Ghana and Mozambique.

Tools & Resources

Community Engagement: Tools and Resources

Get Ready

Community Engagement: Get Ready

Steps you can take before the next crisis:

Next time you plan an activity, write a strategy, or design a training workshop, think about building on community strengths or assets to achieve goals rather than fixing “deficits” or gaps. You can do this in any sort of program. Ask the community which of their strengths, resources, ideas, ideals, and skills they might use to achieve their goal.
If you haven’t yet used technology in community engagement activities yet, give it a try. Plan a small-scale addition to your normal community engagement activities that is appropriate for your community, whether it involves a phone or a megaphone. Using these methods in a crisis will be easier if you are already familiar with them and know which have promise.

Lessons Learned

Uncertainty and Misinformation: Lessons Learned

Rumor tracking can help projects get ahead of misinformation before it takes hold and be ready when it does go viral. Rumors often emerge when: accurate, credible, reliable information is lacking; too much information is circulating; and/or people purposefully spread misinformation. This results in an overload of information, oftentimes contradictory, making separating fact from fiction difficult. Ignoring rumors can be expensive, though. For example, rumors about the polio vaccine in Nigeria resulted in an outbreak response that cost nearly $500 million more than expected.
Uncertainty is a defining feature of crisis: knowledge is incomplete, the situation changes, the future is unknown. Communicating during uncertainty requires flexibility in messaging, building trust in the messenger, and managing fear. Communicators need to constantly consider those elements and alter messaging as needed and select and prepare messengers carefully. Help people manage fear by communicating the concrete actions they can take to stay safe: to be a useful motivator, fear must always be paired with a belief that there is something one can do to protect oneself.
Social media can act as an amplifier of mistrust, misinformation, and disinformation. Because social media travels so fast and so far, it is an important channel to monitor for rumors and act on quickly by using Social Listening.

Case Study

Uncertainty and Misinformation: Case Study

When COVID-19 concerns reached South Africa, project staff observed an abundance of rumors regarding prevention and transmission. The team quickly set out to develop a rumor monitoring system. With help from Breakthrough ACTION’s global team and WHO’s Global Outbreak Alert and Response Network, a process to manage the collection, analysis, and ultimate response to rumors was put together.

Staff used three approaches to better understand uncertainty, especially when it heightened fear. They started by training field workers embedded in communities in four districts. Trainers asked these workers to identify and share rumors they heard in face-to-face conversations as well as those circulating on digital platforms like WhatsApp. A parallel process used social listening tools, Google Analytics and Meltwater, to assess what COVID-19 topics were trending on social media and other online platforms such as fake news websites. Lastly, the project used a computer-assisted telephone interview survey to explore the knowledge, perceptions, beliefs, trust, social norms, and behaviors related to COVID-19.

The project collected data from these approaches on a weekly basis and shared it with the national risk communication and community engagement technical working group, of which Breakthrough ACTION was a member. Along with the National Department of Health, this stakeholder group designed responses to address community concerns and questions.

Government channels directly delivered responses and replies, which built trust. The most common rumors were related to how to prevent coronavirus using home remedies like garlic, lemon, ginger, and herbs. The project supplemented targeted responses with messages about proven prevention measures including hand-washing, facial coverings, and physical distancing. The program built trust by carefully acknowledging when the answers to questions were unknown.

Read more about experiences in Côte d’Ivoire.

Tools & Resources

Uncertainty and Misinformation: Tools and Resources

Get Ready

Uncertainty and Misinformation: Get Ready

Steps you can take before the next crisis:

Set up a social listening system. Social listening can be both an important part of rumor monitoring during a crisis and useful for “regular” health programming. Start now and you’ll be able to understand what people are saying about health topics, services, and challenges related to your project.
Learn more about social and behavior change theory related to misinformation. It is useful for risk communication but the amplification of misinformation through social media makes it an important topic for all health areas. Try reading this journal article to get started: Using social and behavioral science to support COVID-19 pandemic response.

Lessons Learned

Capacity and Skills: Lessons Learned

Organizations will come to the crisis with different existing skill sets. Some units/organizations will be charged with RCCE but have no or limited social and behavior change (SBC) skills. Others will have SBC skills but require skills building in the specific crisis topic. Take a strengths-based approach to skills, capitalizing on what a person or organization does well, and team up with others to fill the gaps.
Take care of your people. They are experiencing the crisis, too. People in leadership positions should talk openly about challenges and model empathy, kindness, trust, and caring. Trusting that your people will do their absolute best in difficult circumstances allows them to be honest about their challenges. Trust and kindness also build a sense of “being in it together” that helps people get through the rough days and keep showing up through it all.

Case Study

Capacity and Skills: Case Study

In Burma, an automated telephone-based system was used to help community health workers in rural, hard-to-reach areas respond to COVID-19. Two Breakthrough ACTION consortium members teamed up, each with different expertise. Save the Children had extensive experience working with rural communities on risk messaging while Viamo was well versed in developing interactive voice response modules for basic mobile phones.

To build skills among the cadre of community health workers who had a basic level of RCCE/SBC knowledge, Breakthrough ACTION staff developed learning modules on messaging for four topics. The topics covered quarantine and COVID-19 transmission, hand and household hygiene, taking care of those who are infected, and breastfeeding while COVID-19 positive.

Key technical content was outlined in a Word document and then synthesized down to five-minute chunks. Each audio message, voiced by actors, combined a monologue with a conversation between two characters to draw in the listener. An interactive aspect was added at the end to assess learning. In the final step to building a COVID-19 skill base, designers wrote a follow-up text that summarized the main points of each module.

The project shared messages with over 5,000 community health workers in seven different languages. Monitoring data showed that messages shared in the lesser spoken languages (Rohingya, Tedim Chin, Kachin, Kayin, and Shan) had high completion rates despite most speakers living in areas with low connectivity. This was attributed to the dearth of information in these languages, making the phone calls vital sources of information.

If a community member did not answer the call or did not completely receive the message, up to nine additional attempts were made to share the message. These attempts included re-sending the message in another language. By using novel approaches like phone-based message recordings to reach key health workers, Breakthrough ACTION built on existing skills to develop new capacities.

Read more about experiences in Indonesia and the Philippines.

Tools & Resources

Capacity and Skills: Tools and Resources

Get Ready

Capacity and Skills: Get Ready

Steps you can take before the next crisis:

Many opportunities are available to build skills in risk communication and community engagement. We highly recommend the READY Initiative for webinars, discussion forums, and other learning opportunities.
Developing kindness is also a skill. Building it in the workplace can make your organization more resilient to crisis and disruption. It may also make you happier. Try these steps:
- Give maximum flexibility in how people work. People feel like you care about them as individuals when you allow them to determine how and where they work. This looks different for every workplace.
- Share when you’ve made a mistake and ask for help. It allows other people to admit their own mistakes and ask for help rather than covering them up.
- Do a values clarification exercise as an office. What matters most to you as a community? What values will help you weather hard times?

Lessons Learned

Data and Monitoring: Lessons Learned

Even in the middle of a crisis, take time early on to develop a monitoring, evaluation, and learning plan with a full set of indicators. You may feel like you can’t make a plan amid rapid change, but having one plan (even if it isn’t perfect) is essential to ensuring data is available on which to base program decisions. Keep it simple: capture what is being done without creating a reporting burden.
Quality and ethics matter as much as ever during a crisis. For example, make sure you adhere to privacy and confidentiality protocols for data and user information and obtain institutional review board approval when appropriate.
When the usual ways of doing monitoring and evaluation aren’t going to work, consider new ways to collect data. This includes partnering with research firms that have phone banks, regular omnibus surveys, and social media metrics (like Facebook Audience Insights). You may not always be able to obtain the data you need and want. Be creative and flexible and keep trying.

Case Study

Data and Monitoring: Case Study

Using the KAP COVID Dashboard to Convince the Vaccine Hesitant

Tools & Resources

Data and Monitoring: Lessons Learned

Get Ready

Data and Monitoring: Get Ready

Steps you can take before the next crisis:

Review the monitoring and evaluation plan for your project. Are the indicators complete, and do they “indicate” project success (i.e., are they meaningful)? Check to see whether over time your project activities have changed and whether your conceptual model or logic framework needs to change, too. When those things change your monitoring and evaluation plan should change to reflect it. Reviewing your current project will sharpen your skills so that when a crisis hits you’ll be in practice!
Explore how to do monitoring and formative studies in a crisis, especially one where you can’t interact with people face-to-face. These include options like SMS and interactive voice response surveys and virtual pretesting. Even when they aren’t yet necessary, try them out in your project in a small way so you’ll be ready when you need them in a big way.

[1] Joint External Evaluation Tool: International Health Regulations (2005). World Health Organization.

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This website is made possible by the support of the American people through the United States Agency for International Development (USAID). The Breakthrough awards are supported by USAID’s Office of Population and Reproductive Health, Bureau for Global Health, under Cooperative Agreements: #AID-OAA-A-17-00017 and #AID-OAA-A-17-00018. Breakthrough ACTION is based at the Johns Hopkins Bloomberg School of Public Health’s Center for Communication Programs. Breakthrough RESEARCH is based at Population Council. The contents of this website are the sole responsibility of Breakthrough ACTION and Breakthrough RESEARCH. The information provided on this website is not official U.S. Government information and does not necessarily represent the views or positions of USAID, the United States Government, Johns Hopkins University, or Population Council.